Introduction

Recently, quality control of medical care is becoming increasingly
more important. In hospitals, departments are required to meet
certain quality standards stated by hospital administration,
and internal audit is a valuable instrument that can be used to
obtain and evaluate treatment outcome data. Even publication
is expected to get increasingly controlled by standardized
guidelines. This rigor serve the surgical specialties in different
ways, as it gives an indication of the level of care provided and
specific information about operational risks encountered. It also
allows for the scientific analysis of factors that might be linked to a
better practice and to improve patient care, and allow comparing
those results with other benchmarks pertaining to surgeons and
institutions [1].

Pediatric brain tumor (PBT) is the second most common form
of childhood cancer, and account for approximately 20% of
childhood cancer diagnoses [2]. Because of the availability of
aggressive combination therapies, including surgical resection,
chemotherapy, radiotherapy, and peripheral blood stem cell
transplantation, overall improvement in outcome has been
observed over the last decade [3-5].

Comprehensive approach to these patients is being implemented
more frequently. For example, although the initial imaging of any
solitary pediatric CNS tumor, might not affect the initial strategy
of surgical intervention (gross total vs. subtotal resection)
histopathological diagnosis and follow up imaging in instrumental
in guiding the whole post-operative care, as well as the prognosis
[6,7].

Lately, several advances and improvements in the histopathological
diagnostics and differentiation of central nervous system (CNS)
tumor subtypes allowed prognostication that was not previously
available. To ensure a uniform and standardized approach, CNS
tumors have been re-classified according to the internationally
accepted World Health Organization (WHO) classification of
brain tumors [8]. Therefore, clinical protocols combine imaging
of PBT and histopathology, and discuss the ramifications of such
combination on outcome of treatment of CNS tumors among the
pediatric population.

The primary aim of this study is to perform an internal quality
assessment of pediatric brain tumor surgery done by the neurosurgery department in the University of Dammam at
the Kingdom of Saudi Arabia. Secondly, this study aims to
contribute to the accumulating data concerning outcome in
pediatric neurosurgery, in order to establish institutional practice
benchmarks.

Methods

The study was conducted at King Fahad Hospital of the University
(KFHU) a tertiary care university teaching hospital with 600 beds
in the Eastern Province of Saudi Arabia. After obtaining our local
institutional research approval, we conducted a retrospective
cohort study of pediatric patients with the diagnosis of PBT in the
last 10 years, from December 2005 till February 2015. During this
period, there was one dedicated pediatric neurosurgeon in our hospital, no pediatric oncologist nor a neuro-oncologist, and no
dedicated diagnostic neuroradiologist. All patients were younger
than 16 years at the time of the first surgery. Data collected from
chart review, collecting data that include demographics, initial
lab investigations, disease comorbidities, management plan, and
outcome. In addition, revising all radiological images, radiological
reports, pathological specimens and pathological reports. We
excluded all DNR (do not resuscitate) patients and, patients
diagnosed with pseudo-tumors (Cysts). Data was entered and
analyzed using SPSS program version 22. All results are displayed
as mean and SD. Categorical variables were compared with the 2
× 2 or Fisher’s Exact Test. Quantitative variables were compared
using the Kruskall-Wallis nonparametric test. The results were
supposed to be statistically significant for p-values <0.05.

Results

A total of 62 charts were reviewed. After exclusions, 45 patients
were included in the final analysis.

The mean age of patients is 7 years (SD ± 4. 5). 62% were males
and 38% were females. 76% were Saudi in nationality. The family
history of PBT was not documented in 55% of charts.

Review of diagnostic imaging revealed that 45% of patients were
operated on the basis of CT alone. Cranial MRI was obtained
the in the remaining 55%. Of those, Diffusion-Weighted imaging
(DWI) was obtained in only 20% of patients. Spinal MRI was done
in scarcely whether preoperatively (8.4%), and postoperatively
(3.3%) respectively.

Intraoperative frozen section histopathological examination
was obtained in 18% of cases. Permanent histopathological
examinations revealed that most of PBT is primary glial in origin
in 78%. Of those the majority (59%) were low-grade lesions,
26% of those were astrocytomas and 8.7% were ependymomas.
Glioblastoma represented 4.3% of our cohort. The remainder
were primitive tumors including PNET, Medulloblastoma,
Pinealblastoma and hemangioblastoma (Table. 1). Only 47% of
tumors were subjected to further genetic analysis. There was rare
dissemination to the spinal cord (2%). Similarly, CSF cytological
analysis was conducted in 2% of patients.

Tumor type

Total (%)

GBM

2 (4.3%)

Astrocytoma

12 (26.6%)

Ependymoma

4 (8.7%)

Germinoma

3 (6.5%)

Hemangioblastoma

1 (2.2%)

Craniopharyngioma

5 (11.1%)

PNET/Medulloblastoma

5 (11.1%)

Pinealblastoma

1 (2.2%)

Oligodendroglioma

2 (4.3%)

Details not available

10 (22.2%)

Total

45(100%)

Table 1: Distribution for each type of PBT.

In total, surgical resection was the primary step in management
in all patients. 78% of patients suffered no morbidity and good
long-term outcome and with a 10-year-progression survival
rate of 64%. Overall survival data is lacking since 80% of patient have no long-term data on record (Figure. 1). No intraoperative
mortality was encountered. However post-surgical mortality
during the hospital stay was 4.4%. The Mean length of hospital
stay was 22 days, with most patients receiving adjuvant therapy
in other institutions.\

Figure 1 Survival Analysis.

Discussion

There is significant improvement in the outcome of treatment
of pediatric CNS tumors, owing to the improvement in the
inter-disciplinary care provided for these patients. This included
improvement in clinical diagnosis, imaging, operative techniques
and adjuvant therapies provided.

Quality-of-care metrics and indicators of patient care in pediatric
Neuro-oncology surgery are hardly available, and a review of the
literature shows noticeable differences in the reported findings
owing to the heterogeneity of criteria experienced when selecting
the type of surgery for each patient, when evaluating the extent
of resection, or when defining surgical complications and their
severity [9].

In this study, we evaluated the practice in our center when
approaching patients with the diagnosis of PBT. Following
our model of care, the neurosurgery department was the
most responsible for caring for the patients, coordinating all
aspects of care. With this, there is extensive collaboration with
a multidisciplinary team including, pediatrics, radiology and,
histopathology departments as well as the oncology department
of other institutions for adjuvant therapy. There is a constant
concern of missing a step of this process and owing to the
variability of practice backgrounds in our hospital, the chances
of this are relatively high given that a standardized protocol or a
flow chart for care does not exist.

Nonetheless, 78% of patients had their treatment without
neurological morbidity after first surgery. This is generally in
line with the reported morbidity of 33% and 54% neurological
complications in recent studies [10,11]. Overall mortality in
our patients with PBT undergoing surgery was found to be 4.4%
which is comparable to the reported rates ranging from 0% to
20% in other studies [12,13].

It is well known that high-volume hospitals and high-volume
surgeons lead to lesser morbidity and mortality [14]. That is why
we always raise a concern given the low volume status in our
hospital. But the attempts to establish benchmarks for our practice
are vital to maintaining safety of the treatment we provide to
PBT patients, e.g., mandating detailed documentation of factors
known to affect patients with PBT and their families. To this
effect we have to move to more regional complimentary network
of hospitals that serve PBT to provide primary and adjuvant
therapies in a streamlined fashion. We emphasize the value of
the human factor too, with dedicated pediatric neurosurgeons,
neuro-oncologist, and neuro-radiologists creating a specialized
multidisciplinary team acquainted with the updates rapidly
occurring in the field. This will improve the care that the patients
should receive in our center and help maintain this benefit for the
future and most importantly establish metrics for us to continue to improve our care and compare our performance to that of the
rest of the practice institutions.

Conclusion

Despite the lack of a sub-specialized multidisciplinary team caring
for patients with PBT, the overall surgical mortality rate in KFUH
was (4.4%) with a 22% morbidity, which is keeping with those
of high-volume neurological centers. Nonetheless, logistical
improvements and investing in the specialties involved in caring
for patients with PBT will allow maintaining this outcome and
create quality metrics that can be used in the future to gauge our
progress.

Acknowledgement

The authors wish to thank Dr. Faisal Al-Ousi and Dr. Mohammed
AlAftan for their assistance in data collection.